SURAT PERMOHONAN

SURAT IZIN USAHA MIKRO KECIL

Yth......................................
4 x 6 Pas Foto
...........................................
(Pemilik Usaha)
di-
P A T I

No. Registrasi : ............................................................

No. Surat Permohonan : ............................................................
No. Izin Usaha : ............................................................

1. Nama Pemilik Usaha : .........................................................................

2. NIK : .........................................................................
3. Alamat : .........................................................................
Provinsi : .........................................................................
Kabupaten/Kota : .........................................................................
Kecamatan : .........................................................................
Desa : .........................................................................
Nama Jalan/Dusun : .........................................................................
Kode Pos : .........................................................................
No. Telp : .........................................................................
4. Nama Usaha/Nama Toko : .........................................................................
5. Alamat Usaha/Toko : .........................................................................
6. Kegiatan Usaha : .........................................................................
7. Jumlah Modal Usaha : .........................................................................
8. Sarana Yang Digunakan : .........................................................................
9. NPWP : .........................................................................

Pendamping IUMK Pemilik Usaha

(......................................) (....................................)

Kepala Desa/Kelurahan

(......................................)
 SURAT PERMOHONAN
SURAT IZIN USAHA MIKRO KECIL

Yth. Camat Dukuhseti

di-
Dukuhseti

No. Registrasi : ............................................................

No. Surat Permohonan : ............................................................
No. Izin Usaha : ............................................................
1. Nama Pemilik Usaha : .........................................................................
2. NIK : .........................................................................
3. Alamat : .........................................................................
Provinsi : .........................................................................
Kabupaten/Kota : .........................................................................
Kecamatan : .........................................................................
Desa : .........................................................................
Nama Jalan/Dusun : .........................................................................
Kode Pos : .........................................................................
No. Telp : .........................................................................
4. Nama Usaha/Nama Toko : .........................................................................
5. Alamat Usaha/Toko : .........................................................................
6. Kegiatan Usaha : .........................................................................
7. Jumlah Modal Usaha : .........................................................................
8. Omset : .........................................................................
9. Jumlah Tenaga Kerja : ..................... (P = ................ L = ....................)
10. Sarana Yang Digunakan : .........................................................................
11. NPWP (tidak wajib) : .........................................................................
Pemilik Usaha
4 x 6 Pas Foto
(Pemilik Usaha)

(.........................................)

Kepala Desa/Kelurahan Pendamping IUMK

..........................................

(..............................................) (...............................................)
Lampiran:
1. Fotocopy KTP
2. Foto berwarna 4 x 6, 2 lembar
3. Fotocopy KK (Kartu Keluarga)
 FORMULIR APLIKASI PENDATAAN UMKM KABUPATEN PATI
TAHUN ..................

1. Nama UMKM : ..............................................................................

2. Nama Pemilik : ..............................................................................
3. NIK : ..............................................................................
4. Nomor NPWP : ..............................................................................
5. Jenis Kelamin :L / P
6. Tempat, Tanggal Lahir (Umur) : ..............................................................................
7. Alamat :
a. Usaha : ..............................................................................
..............................................................................
b. Tempat Tinggal : ..............................................................................
..............................................................................
8. Contact Person (HP) : ..............................................................................
9. Nama Produk/Spesifik : ..............................................................................
10. Jenis Usaha : ..............................................................................
11. Kapasitas Produk/bulan : ....................................................... (kg/liter/buah)
12. Asset : ..............................................................................
13. Omzet/tahun : ..............................................................................
14. Jumlah Tenaga Kerja : a. Laki-laki: ...... b. Perempuan: ...... c. Jumlah: .....
15. Tahun Mulai Usaha : ..............................................................................
16. Modal Awal : ..............................................................................
17. Sumber Permodalan *) : a. Sendiri
b. Pinjaman Lembaga Keuangan
c. Lain-lain ............................................................
18. Perijinan yang dimiliki *) : a. IUMK b. SIUP c. TDI d. TDP
e. P-IRT f. Belum
19. Sertifikasi Produk *) : a. Merk b. Cipta c. Paten d. Halal e. Belum
20. Daerah Pemasaran *) : a.Lokal b.Kabupaten c.Regional
d.Nasional e.Eksport
21. Skala Usaha : ..............................................................................
22. Sektor Usaha : ..............................................................................
23. Pelatihan yang Diikuti : ..............................................................................
..............................................................................

PELAKU UMKM PETUGAS PENDATA

................................................... .............................................